Provider Demographics
NPI:1073202305
Name:MILLER, SHONDA J (RDN)
Entity Type:Individual
Prefix:
First Name:SHONDA
Middle Name:J
Last Name:MILLER
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:260-373-4280
Mailing Address - Fax:
Practice Address - Street 1:11109 PARKVIEW PLAZA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1701
Practice Address - Country:US
Practice Address - Phone:260-373-4280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37003541A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered